You Down With 13(d)? Yeah, You Know Me: Responding to Health Insurer Reimbursement Requests

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Occasionally, when a workers’ compensation claim is initiated, medical bills are paid by the claimant’s private health insurance. If this happens, you may receive correspondence from the health insurer asking for reimbursement. What should you do in that situation?

The short answer is that you have no obligation to respond to a direct demand for reimbursement. However, there is a process for reimbursement. This is where the Health Insurer Match Program (HIMP) comes into play.

Per the Board, “health insurers may submit information regarding payments on behalf of their members, including name, Social Security number, gender, date of birth, and treatment date, in electronic form to the Workers’ Compensation Board (’Board’) in order to identify injured workers who have filed workers’ compensation claims. The Board then notifies the health insurer of those members for which there is a full or partial match, depending on which information fields are identical in both the health insurer’s and the Board’s records.”

In the event of a “full match,” the health insurer is added as a party of interest who receives notice of events in the case. Once the Board determines that the claim is compensable, the health insurer gains access to the Board’s electronic case files and can submit for reimbursement payments for any treatment that is causally related to the compensable work injury pursuant to Workers’ Compensation Law Section 13(d)(1). In determining compensability, the Board examines whether there was an accident or occupational disease, notice, and causal relationship between the injury and the accident.

Reimbursement shall be at the lesser of what the health insurer actually paid or the Board’s fee schedule for such treatment under Workers’ Compensation Law Section 113(d)(1). Disputes over claims for reimbursement are subject to mandatory arbitration, which is presently administered by the American Arbitration Association.

In short, to receive reimbursement, the private insurer has to submit information on the claim to the Board. The Board will then look for a matching claim. If a match is found, then they will gain access to the claim and can file a request for reimbursement either at the fee schedule or the total amount paid — whichever is less. If there is any dispute, then it is sent for mandatory arbitration.

So, as noted above, if you receive a request (or demand) for reimbursement of this type, you do not need to do anything on your end. The best practice, however, would be to inform the insurer of the process and tell them to contact the Board.

Note that as this is a process subject to arbitration, this issue should not be presented to or resolved by a workers’ compensation law judge.

The health insurer must contact the Board in order for their reimbursement request to be processed. To read more, click here.

There is not a clear answer as to what the insurer could do about any shortfall between the reimbursable amount and the amount paid. The logical next step would be for the insurer to seek a refund from the health care provider after informing the provider that the claim is under workers’ compensation and that they must comply with the New York fee schedule.